Failed Myotomy Research Articles

Robotic redo Heller myotomy: how I do it?

Despite the high success rate associated with Heller myotomy in the treatment of primary achalasia, symptom persistence or relapse occurs in approximately 10-20% of patients. Unfortunately, the ideal treatment after failed myotomy is not well established yet. We present a didactical video with a stepwise technique to perform a robotic revisional procedure after failed Heller myotomy. In this report, each surgical step is thoroughly described and visually represented with useful technical tips that might help in improving surgical results of revisional Heller myotomy. In patients with previous surgical myotomy, the robotic platform with its high-definition magnified view and EndoWrist instruments allow for a safe and precise redo surgical myotomy. Despite its improved surgical capabilities, the role of robotic redo Heller myotomy in the treatment algorithm of patients with recurrent symptoms after failed surgical myotomy should be further explored.

Role of functional luminal imaging probe in the management of postmyotomy clinical failure

A small percentage of patients with esophageal dysmotility disorders (EDDs) fail to improve or relapse after management by laparoscopic Heller myotomy (LHM) and peroral endoscopic myotomy (POEM). In this study, we aimed to describe the role of functional luminal imaging probe (FLIP) in identifying patients who might benefit from lower esophageal sphincter (LES)-directed retreatment. This was a retrospective study at 6 tertiary care centers (United States, 4; Europe, 1; Asia, 1) between January 2015 and April 2021 involving patients with prior failed myotomy. The primary outcome was the impact of the use of FLIP on the management of patients with prior failed myotomy. One hundred twenty-three patients (62 women [50%]; mean age, 53 ± 21.1 years) who underwent LHM (n= 53, 43%) or POEM (n= 70, 57%) for the management of achalasia (n= 98) or other EDDs (n= 25) had clinical failure at a median time of 10.8 months (interquartile range, .8-17.3) postprocedure. Twenty-nine patients had apposing "abnormal" diagnoses in terms of integrated relaxation pressure (IRP) >15mm Hg on HRM and distensibility index (DI)<2.8mm2/mm Hg on FLIP, with ultimate change in management noted in 15 patients (10 directed toward conservative management, 5 directed toward LES-directed retreatment). The impact of FLIP on both diagnosis and management was noted in 15 of 29 patients (52%). In the subgroup analysis of 44 patients who underwent LES-directed retreatment, clinical success was highest among patients with both abnormal IRP and DI (21/25 [84%]) versus patients with only abnormal IRP (8/14 [57%]) or only abnormal DI (3/5 [60%], P= .04), with DI at 40-mL distension volume on FLIP identified as an independent predictor of clinical success (odd ratio, 1.51; 95% confidence interval, 1.02-2.1; P= .03). The finding of this study further suggests the important role of using FLIP in addition to HRM in evaluating patients with clinical failure postmyotomy.

Peroral endoscopic myectomy: a novel thought to reduce recurrence after previous failed myotomy

A 45-year-old man presented with a history of dysphagia and regurgitation for 8 years. He was diagnosed with type II achalasia cardia and underwent Heller’s myotomy without fundoplication 4 years earlier. The results of the present evaluation, including symptom analysis, EGD, timed barium esophagogram, and esophageal manometry, suggested a relapse. Treatment options were discussed, and peroral endoscopic myotomy (POEM) was performed. The posterior route (5 o’clock) was chosen for POEM to avoid possible submucosal fibrosis along the anterior route.

Tu1220 Is Redo-Peroral Endoscopic Myotomy After Prior Failed Myotomy for Achalasia Patients Effective and Safe Therapeutic Modality?

Tu1220 Is Redo-Peroral Endoscopic Myotomy After Prior Failed Myotomy for Achalasia Patients Effective and Safe Therapeutic Modality?

Peroral Endoscopic Myotomy (POEM): Feasible as Reoperation Following Heller Myotomy

PurposeThe purpose of this study was to demonstrate the feasibility of performing peroral endoscopic myotomy (POEM) in the management of recurrent achalasia after failed myotomy. MethodsEight patients presented to our institution between October 2010 and June 2013 with recurrent/persistent symptoms after prior laparoscopic Heller myotomy. Three patients underwent redo laparoscopic Heller myotomy, and five patients consented to redo myotomy with POEM. ResultsDemographics were similar between the groups with exception of age (POEM 69.5 vs. laparoscopic Heller myotomy (LHM) 34.5, p = 0.003). Preoperative Eckardt scores, motility, and prior interventions were not significantly different. Three patients who underwent POEM and two who underwent laparoscopic Heller myotomy had prior fundoplication. There was one perforation identified after laparoscopic Heller myotomy and one patient with persistent subcutaneous emphysema after POEM. Both POEM and laparoscopic Heller myotomy demonstrated significant improvement in symptoms and Eckardt scores at average follow-up of approximately 5 months (p < 0.05). ConclusionPOEM is a feasible option for patients after failed myotomy even in the presence of prior fundoplication. The procedure can be performed safely using a similar technique as for primary myotomy with the exception of creating the myotomy laterally along the right side of the esophagus and lesser curvature avoiding the previous anterior myotomy.

Endoscopic, Radiologic, and Manometric Features of an Incomplete Heller Myotomy for Achalasia

Purpose: Laparoscopic Heller myotomy is an effective surgical therapy for idiopathic achalasia. Unfortunately 5–10% of patients develop recurrent dysphagia or chest pain in the early postoperative period. The most common cause for recurrence is an incomplete myotomy, in which the muscle fibers at the distal end of the myotomy are not completely released. Proper recognition of an incomplete myotomy is poorly described in the literature and the best approach to therapy is unclear. Methods: A 63 yo female with diabetes and hypertension who presented with dysphagia to solids and liquids and a 40 pound weight loss was diagnosed with achalasia on barium esophogram and manometry. The manometry showed a hypertensive lower esophageal sphincter (LES), incomplete LES relaxation, and aperistalsis with low-amplitude, simultaneous contractions after all wet swallows. She underwent a laparoscopic Heller myotomy with Dor fundoplication which was initially successful. However, she returned one year later with recurrent dysphagia, chest pain and weight loss. Results: Evaluation with esophogram and endoscopy showed a focal distal stenosis lacking the appearance of a peptic or fibrotic stricture (see Figure). Repeat manometry showed an isolated high-pressure zone (HPZ) with failure of relaxation within the proximal margin of the LES. This HPZ was consistent with intact residual LES fibers from an incomplete myotomy. Thus, pneumatic dilation (PD) was chosen as the therapeutic approach instead of a repeat surgery. The dilation was performed with a 3 cm balloon and was successful – at follow-up 1 and 4 months later she reported resolution of dysphagia and chest pain and had a weight gain of 8 pounds.FigureConclusion: This case nicely illustrates what might be observed in a patient with achalasia and recurrent symptoms due to an incomplete myotomy. A focal residual HPZ at the proximal end of the LES was observed on endoscopy, radiology, and manometry. Our case is interesting in that the residual HPZ was located at the proximal rather than distal margin of the LES. The use of PD following incomplete myotomy has been reported in the literature with success rates as high as 80 percent. More studies are needed to improve recognition of an incomplete myotomy and to develop criteria for the selection of patients who would benefit most from PD after failed myotomy.

Pneumatic Dilation for the Treatment of Achalasia in Untreated Patients and Patients With Failed Heller Myotomy

Laparoscopic Heller myotomy (HM) has become an increasingly preferred modality to treat achalasia. However, the treatment course after a failed myotomy is controversial with fears that pneumatic dilation (PD) has high perforation risk. To compare success and safety of graded PD with Rigiflex balloons in achalasia patients without a prior HM (untreated cases) and those with a failed HM. A total of 108 patients were retrospectively evaluated: 96 untreated cases (53 male, 43 female, mean age 51 years) and 12 failed HM(7 male, 5 female, mean age 54 years). Symptoms (dysphagia and regurgitation) and physiologic studies, lower esophageal sphincter pressure (LESP) and timed barium swallow, assessed pre- and post-PD. Success was defined as: 1) symptom improvement to </=2 to 4 times per week, and 2) >/=80% decrease in 5-minute barium column height from initial timed barium swallow. A total of 139 PDs performed (117 untreated cases, 22 failed HM): 2 perforations in untreated cases and none in failed HM group. Baseline demographics were similar, but failed HM patients had significantly lower LESP and timed barium swallow columns. Despite less LES resistance, failed HM group (symptom and physiologic success: 50% and 10%) did not do as well after PD as compared with untreated cases (symptom and physiologic success: 74% and 52%, respectively). Five failed HM patients had good symptom relief after PD compared with poor responders these patients were older (>50 years) and had LESP >17 mm Hg. PD perforation risk is not higher after HM. Despite lower LES pressure, patients undergoing PD after failed HM do not do as well as untreated cases. Factors predicting better outcome include older age and higher LES pressure.

A CONSULTATIVE GASTROENTEROLOGIST (CG) PERSPECTIVE ON POST-MYOTOMY SYMPTOMS IN ACHALASIA PATIENTS

Purpose: Heller myotomy is a frequent treatment for achalasia. Persistent or new symptoms after myotomy represent a complicated problem facing the CG. The aim of this study is to identify the characteristics of patients with post-myotomy symptoms. Methods: Retrospective review of 11 patients (4 males, 7 females; mean age 48 yrs) seen in one CG practice for post-myotomy symptoms. Patients divided into: - Persistent symptoms: persistent dysphagia after surgery. - New symptoms: new heartburn and regurgitation after surgery. Results: Persistent symptoms: 8 patients; all had persistent dysphagia as their only symptom after myotomy. All of these patients had a Heller myotomy combined with a fundoplication. They all reported worsening of their dysphagia 2 months to 2 years after the surgery. Pneumatic dilatations of the lower esophageal sphincter (LES) were performed in all these patients with no improvement or only a short-lived (less than 2 months) symptom improvement. 3 patients also had LES Botox injections with no symptom improvement. Two of these patients have required esophagectomy. - New symptoms: 3 patients; All had persistent dysphagia after myotomy, but also complained of new heartburn and regurgitation symptoms. All of these patients did not have a fundoplication with the myotomy. Only one patient had an improvement in reflux symptoms with a proton pump inhibitor. Conclusions: Failed myotomy occurs and often results in referral to a CG. Follow-up of myotomy patients is important to identify persistent or new symptoms.